Applicability and clinical utility of the German rivermead post-concussion symptoms questionnaire in proxies of children after traumatic brain injury: an instrument validation study.

BACKGROUND: The German Rivermead Post-Concussion Symptoms Questionnaire (RPQ) can be used to assess post-concussion symptoms (PCS) after traumatic brain injury (TBI) in adults, adolescents, and children. METHODS: In this study, we examined the psychometric properties of the German RPQ proxy version (N = 146) for children (8-12 years) after TBI at the item, total and scale score level. Construct validity was analyzed using rank correlations with the proxy-assessed Post-Concussion Symptoms Inventory (PCSI-P), the Patient Health Questionnaire 9 (PHQ-9), and the Generalized Anxiety Disorder Scale 7 (GAD-7). Furthermore, sensitivity testing was performed concerning subjects' sociodemographic and injury-related characteristics. Differential item functioning (DIF) was analyzed to assess the comparability of RPQ proxy ratings for children with those for adolescents. RESULTS: Good internal consistency was demonstrated regarding Cronbach's α (0.81-0.90) and McDonald's ω (0.84-0.92). The factorial validity of a three-factor model was superior to the original one-factor model. Proxy ratings of the RPQ total and scale scores were strongly correlated with the PCSI-P (ϱ = 0.50-0.69), as well as moderately to strongly correlated with the PHQ-9 (ϱ = 0.49-0.65) and the GAD-7 (ϱ = 0.44-0.64). The DIF analysis revealed no relevant differences between the child and adolescent proxy versions. CONCLUSIONS: The German RPQ proxy is a psychometrically reliable and valid instrument for assessing PCS in children after TBI. Therefore, RPQ self- and proxy-ratings can be used to assess PCS in childhood as well as along the lifespan of an individual after TBI.

Unresolved attachment and identity diffusion in adolescence.

This study examined the severity of unresolved attachment underlying adolescent identity diffusion. Our sample consisted of 180 inpatient adolescents aged 14 to 18 years (77% female, M age = 15.13, SD = 1.35; 23% male, M age = 14.85, SD = 1.41) and 84 age-matched non-clinical adolescents (52% female, M age = 16.14, SD = 1.21; 48% males, M age = 15.98, SD = 1.07). We used the Adult Attachment Projective Picture System (AAP) interview to assess attachment representations and the Assessment of Identity Development in Adolescence (AIDA) questionnaire to evaluate the severity of identity diffusion. Our results demonstrate a higher amount of unresolved attachment and identity diffusion in the patient sample than in the control sample. Furthermore, patients with an unresolved attachment status scored higher on identity diffusion than those with no unresolved attachment pattern. Interestingly, this was not found in the control group. Furthermore, patients with a greater severity of unresolved attachment showed the highest maladaptive identity development scores. Psychotherapeutic interventions integrating attachment-related aspects might be useful to treat young people with identity diffusion.

Changes in Attachment Representation and Personality Organization in Transference-Focused Psychotherapy.

OBJECTIVE: The aim of this article was to construct an empirical bridge between object relations theory and attachment theory by investigating how researchers in both traditions have contributed to understanding and assessing identity diffusion (a keystone of personality pathology) and object relations in patients with borderline personality disorder during 1 year of transference-focused psychotherapy (TFP). METHODS: The Adult Attachment Interview (AAI) and the Structured Interview of Personality Organization (STIPO) were administered to patients (N=104, all women) before and after 1 year of treatment. This study was part of a randomized controlled trial in which 104 patients with borderline personality disorder were randomly assigned to receive either TFP (a manualized, structured psychodynamic treatment approach) or treatment by experienced community psychotherapists. Changes on the AAI in attachment representations, narrative coherence, and reflective function were examined for their associations with changes on the STIPO in identity, object relations, and aggression. RESULTS: Patients who shifted from disorganized (unresolved) to organized attachment on the AAI after 1 year of TFP (but not treatment by experienced community psychotherapists) showed hypothesized improvements in domains of personality organization on the STIPO, including identity, object relations, and aggression. Those who did not change from disorganized (unresolved) to organized attachment improved only in the domain of aggression. CONCLUSIONS: These findings highlight the centrality of identity diffusion to borderline personality disorder pathology and the importance of targeting it in treatment. Furthermore, the results suggest that identity may be indexed by measures of attachment security, narrative coherence, and personality organization.

Attachment status is associated with grey matter recovery in adolescent anorexia nervosa: Findings from a longitudinal study.

The aim of the present study was to investigate whether grey matter (GM) reductions in acute anorexia nervosa (AN) are (i) valid for adolescents (age 14-18 years), (ii) reversible following short-term psychotherapeutic and nutritional therapy and (iii) depend on psychological components like attachment trauma. 3T MRI including a high-resolution T1 MPRAGE was performed in 22 female adolescents in the acute state of AN (age: 15.2 ± 1.2 years) and after weight restoration (duration: 2.6 ± 1 months, n = 18) and compared with 18 gender-matched healthy controls. The Adult Attachment Projective Picture System was used to classify resolved and unresolved attachment patterns. GM decreases were localized in extensive cortical areas including the insula, prefrontal and cingulate cortices as well as subcortical regions during acute AN, which partially increased after therapy with a relative sparing of the hippocampus and parahippocampal gyrus. The resolved group showed more GM recovery in regions of the left hippocampus and parahippocampal gyrus, bilateral cerebellar regions, right precuneus and adjacent cingulate cortices relative to the unresolved pattern. Structural anomalies in adolescent AN that recovered after treatment may be primarily the consequence of malnutrition, whereas several regions did not display significant recovery. Attachment status seems to influence region-specific GM recovery.

[Attachment Representations and Burnout of Social Workers]. / Zu Bindungsrepräsentationen und Burnout bei sozialpädagogischen Fachpersonen.

This paper examines the distribution of attachment representations among social work professionals using the Adult Attachment Projective Picture System (AAP; George, West, Pettem, 1997). In this sample, the influence of attachment on the occurrence of burnout syndrome is investigated, as this is considered as a trigger for further mental and physical illnesses. For this purpose, 79 social pedagogical professionals from the German-speaking part of Switzerland were examined over four time points using the Burnout Screening Scales - BOSS. The following distribution of attachment representations was found using the AAP: 25.3 % secure, 38.0 % insecure dismissing, 27.8 % insecure preoccupied, and 8.9 % unresolved trauma. This distribution differs significantly from other samples of non-clinical adults and psychotherapists. Interestingly, no general associations emerged between insecure attachment representations and burnout. A significant positive correlation was shown between "unresolved trauma" and the suspected diagnosis of "burnout occupation". The so far few but contradictory empirical findings on attachment representations among professionals require further research activities as well as an intensive sensitization with regard to attachment theory in basic and further training courses and a further establishment of self-awareness and supervision components in all psychosocial fields of work.

Non-suicidal self-injury and attachment trauma in adolescent inpatients with psychiatric disorders.

This study examined how non-suicidal self-injury disorder (NSSID) differs with respect to mental disorders, gender and attachment status in adolescent psychiatric patients. In particular, we analyzed attachment-related traumatic material underlying adolescent NSSID. Our sample consisted of 137 in-patient adolescents aged 12 to 18 years (73% female, Mage = 15.09, SD = 1.44; 27% male, Mage = 14.65, SD = 1.53). Forty-four patients (32.1%) fulfilled the diagnostic criteria for NSSID according to the DSM-5 and ninety-three patients (67.9%) did not meet diagnostic criteria for NSSID. Our results revealed a higher prevalence of NSSID in female patients and in patients with mood disorders. In the total sample, 52% of our in-patients were classified with an unresolved attachment status. The diagnostic subgroup analysis demonstrated a higher percentage of unresolved attachment status only in patients with eating disorders and NSSID. However, our in-depth analysis of the total sample revealed that patients with NSSID demonstrated more traumatic material in their attachment interviews indicating a greater severity of attachment trauma. In particular the theme of helplessness in interpersonal conflicts left them in a state of attachment dysregulation. Intervention strategies targeting traumatic attachment-related themes might be useful to reduce the number of adolescents engaging in NSSI.

A Bifactor Model of Personality Organization.

The aim of this study was to explore the viability of a bifactor model for the Inventory of Personality Organization (IPO), which is a self-report measure of personality functioning based on Kernberg's model of personality organization. A heterogeneous, predominantly clinical sample (N = 616) completed the German 83-item version of the IPO. Confirmatory and Exploratory Factor Analyses were applied to explore the factor structure of the IPO. We were able to establish a bifactor model with a general factor of personality functioning and three specific factors (Aggression, Reality Testing, Moral Values), which represent additional dimensions of personality organization. Virtually all items showed substantial positive loadings on the general factor, explaining roughly 66% of the common variance. Furthermore, we found support for convergent and discriminant validity of general and specific factors with regard to interview-based assessments of personality disorders and personality organization. The results lend support to a bifactor approach to Kernberg's model of personality organization. We also present a 30-item brief form of the IPO that efficiently implements the bifactor approach and may be further validated in future studies.

The role of attachment characteristics in dialectical behavior therapy for patients with borderline personality disorder.

Attachment characteristics play a key role in understanding borderline-specific problems with respect to childhood maltreatment. The aim of this study was to investigate how attachment representations may influence the trajectory of change in a 1-year outpatient dialectical behavior therapy (DBT) for patients with borderline personality disorder (BPD). Attachment representations were assessed in 26 BPD patients and 26 healthy controls (HC) using the Adult Attachment Projective Picture System (AAP) before treatment. Borderline and global symptom severity and interpersonal problems were examined before, during, and after completing the intervention. Analysis of variance and stepwise hierarchical regression analyses were used to explore the course of symptomatology. As expected, BPD patients displayed a predominance of unresolved attachment in the AAP compared with HC, by showing a lack of ability to integrate attachment related trauma. Whereas both resolved and unresolved attachment groups revealed significant improvement in symptom severity during treatment, dimensional AAP scores showed differences. Patients with higher scores in "synchrony" demonstrated more indicators of mutual care in their narratives to dyadic pictures and displayed a significantly stronger decrease of interpersonal problems than patients with lower synchrony scores. Assessing attachment representations prior to DBT might provide a helpful insight into individual attachment related resources or lack of these capacities. Responsiveness and synchrony in dyadic interactions with significant others are crucial for healthy interpersonal relations. A stronger therapeutic focus on the patient's capacity to show synchrony in dyadic attachment situations might improve the patient's interpersonal problems towards sensitive and mutual interaction.

[Differences in Conflict-Based Play Behavior, Socio-Emotional and Cognitive Development of Preterm Children Compared to Full-Term Children at Preschool Age]. / Unterschiede im konfliktbasierten Spielverhalten, der sozioemotionalen und kognitiven Entwicklung von Frühgeborenen und Termingeborenen im Vorschulalter.

Differences in Conflict-Based Play Behavior, Socio-Emotional and Cognitive Development of Preterm Children Compared to Full-Term Children at Preschool Age Preterm children are at increased risk for socio-emotional and cognitive developmental difficulties at preschool age. This study investigates whether preterm children (n = 50) at the age of five years show different socio-emotional competencies in conflict situations and in the corresponding conflict resolution capacity in comparison to full-term children (n = 50). For this purpose, the MacArthur Story Stem Battery was used as the central examination method. In addition, parents completed the Strengths and Difficulties Questionnaire to obtain information about the children's behavior; moreover, the Wechsler Preschool and Primary Scale of Intelligence - Third Edition was applied to examine cognitive development. The parental reports did not reveal any behavioral differences between preterm and term children. However, significant group differences regarding their play behavior were detected. In their narratives, preterm children included content themes of interpersonal conflict and dysregulation more frequently compared to term born controls. Concerning empathic and moral themes and narrative coherence, no group difference could be detected. This could indicate that preterm children show no clinically manifest behavioral disorders at preschool age, but differences concerning intrapsychic experience compared to controls. In addition, preterm children had significantly lower IQ scores than term-born controls. Gestational age was a significant predictor of IQ and hyperactivity and attention problems. The results clarify the need for long term clinical follow up of preterm children and should be used to provide more specific care and support.

Facial Behavior During an Attachment Interview in Patients With Complicated Grief.

The present study investigated differences in various aspects of facial behavior among female patients with complicated grief (CG; n = 18) and healthy controls (n = 18) during the assessment of their attachment representation using the Adult Attachment Projective Picture System. All patients were classified with an unresolved attachment status. On a behavioral level, they demonstrated longer gazing behavior away from the interviewer and the picture stimuli, more speech pauses, less smiling toward the interviewer, and more crying, especially in response to stimuli portraying the theme of loss. Focusing on the in-depth analysis of death-related stimuli using the Facial Action Coding System, patients demonstrated less facial affective behavior, less disgust, and less smiling in response to these stimuli compared with the healthy controls. The impaired capacity of patients with CG responding in an affective appropriate manner regarding bereavement might be interpreted as a specific emotion dysregulation when their attachment and mourning system is activated.

Disorder-specific attachment characteristics and experiences of childhood abuse and neglect in adolescents with anorexia nervosa and a major depressive episode.

For the first time, the present study investigates disorder-specific attachment characteristics and childhood trauma in adolescent inpatients with anorexia nervosa (n = 30, girls/boys: 28/2, age: M = 14.84, SD = 1.20), a major depressive episode (n = 30, girls/boys: 27/3, age: M = 15.14, SD = 1.50), and controls (n = 60, girls/boys: 44/16, age: M = 16.10, SD = 1.20). We used the Structured Clinical Interview to diagnose Axis I disorders, the Adult Attachment Projective Picture System to classify attachment representations, and the Childhood Trauma Questionnaire to assess child maltreatment. Our findings demonstrate an overrepresentation of the unresolved attachment status in the patient samples. A one-way analysis of variance succeeded by Bonferroni post hoc tests indicated that adolescents with anorexia nervosa show more isolation and dissolution of boundaries between life and death when confronted with situations of solitude. Although they report moderate to severe levels of traumatic childhood experiences, they tend to minimize those. Adolescents with a major depressive episode report higher levels of emotional abuse and neglect in their childhood, leaving them in a state of failed protection and danger during attachment distress. Integrating these attachment-related characteristics into specific psychotherapeutic interventions might be associated with a better outcome in that age group.

Use of the Adult Attachment Projective Picture System in the formulation of a case of an adolescent refugee with PTSD.

Forced displacements and their psychosocial consequences in adolescent refugees and their families have received increasing attention in recent years. Although supportive family relations play a key role in buffering the impact of traumatization in adolescents, parental ability to provide such is often subject to extreme pressure. Under conditions of forced dislocation and fear, maladaptive interpersonal strategies in the parent-child relationships may develop, contributing to the onset of psychopathology. We explore new aspects of attachment-related issues for the understanding and treatment of adolescent refugees who have experienced multiple traumas in their childhood. We used a multimethod assessment battery including the Adult Attachment Projective Picture System (AAP), the Structured Clinical Interview, the Youth Self Report and the Wechsler Intelligence Scale in an adolescent boy with post-traumatic stress disorder (PTSD). Our subject was an adolescent refugee from the Middle East who demonstrated an unresolved attachment when confronted with loss and fear. His responses on the AAP evoked aspects of insecure-unresolved attachment, including his belief that it is not safe to trust in attachment figures, his limited access to traumatic attachment experiences, his impaired ability to take concrete actions when dealing with threatening attachment situations and the unintentional role-reversal shed new light on our understanding of his traumatic experiences, family functioning and psychopathological symptoms. Our results demonstrate the utility of the AAP in an adolescent refugee with PTSD by expanding our knowledge of a diverse range of experiences across the interpersonal, cognitive, cultural and developmental contexts that formed the basis for an individualized treatment plan.

Changes in Attachment Representation in Psychotherapy: Is Reflective Functioning the Crucial Factor?

OBJECTIVES: The study analyzed the interdependence of change in attachment representation and reflective functioning (RF) in psychotherapy. METHODS: RF data from 63 female borderline personality disorder (BPD) patients were analyzed with respect to change of attachment representation (from insecure to secure and from unresolved to resolved) fromthree angles: (1) RF as a moderator variable, (2) RF as an outcome variable, and (3) RF changes over one year of treatment. RESULTS: Patients who changed to a resolved attachment classification showed higher RF before treatment and at follow-up than patients who remained unresolved (RF = 3.0 vs. RF = 2.14, p = 0.039; and RF = 3.4 vs. RF = 2.36, p = 0.002). Similar results were found for changes from insecure to secure. CONCLUSION: A higher RF level before psychotherapy proved to be a moderator for change in attachment representation. Patients with unresolved attachment and low-level RF at the outset had the least chance for representational change during the first year of psychotherapy.

[Attachment Based Short Intervention During Inpatient Treatment of Adolescents]. / Bindungsbezogene Kurzintervention im Rahmen stationärer Behandlung bei Jugendlichen.

Attachment Based Short Intervention During Inpatient Treatment of Adolescents In clinical attachment research the established and economic Adult Attachment Projective Picture System (AAP) has been increasingly used in the past few years to assess the attachment representations in adults and recent studies demonstrated sufficient validity for assessing attachment representations in adolescents. Apart from coding attachment classifications, the AAP provides useful and clinically valid information concerning attachment related defences, aspects of capacity to act and synchrony in relationships and emotion regulation strategies with respect to attachment related traumatic experiences. These valuable aspects with respect to individual resources led to the conceptualization to implement the AAP in the therapeutic setting as a feedback tool. In this pilot case we report on an adolescent patient in an inpatient setting. The therapist received an individualized feedback on the patients' AAP to focus on specific attachment related themes used as a short intervention respective an add-on treatment. This paper presents the first results of this new approach by demonstrating the potential therapeutic effects and process of therapy.

Exploring the effectiveness of combined mentalization-based group therapy and dialectical behaviour therapy for inpatients with borderline personality disorder - A pilot study.

OBJECTIVES: Borderline personality disorder (BPD) is characterized by emotional instability, interpersonal dysfunction, and other features that typically develop before a background of insecure attachment and traumatic experiences. Dialectical behaviour therapy (DBT) has proven highly effective in reducing self-harm and improving emotion regulation, whereby problems concerning social cognition, which are also characteristic of BPD, may need additional approaches such as mentalization-based treatment (MBT). METHODS: Here, we examined, in a pilot study, the effectiveness of MBT given adjunct to DBT, compared to DBT alone, in an inpatient sample with BPD, whereby mentalization was measured using a novel cartoon-based task. RESULTS: Both treatments were highly effective in reducing symptom severity. The combination of DBT and MBT was superior in reducing fearful attachment and in improving affective mentalizing. CONCLUSIONS: Mentalization-based treatment in combination with DBT may improve certain aspects of social cognitive skills and attachment security, as compared to DBT alone, although the exact mechanisms that led to these changes need to be studied further. PRACTITIONER POINTS: Clinical implications Dialectical behaviour therapy (DBT) can usefully be combined with mentalization-based treatment (MBT). The combination of DBT and MBT reduces self-harm more than DBT alone. DBT plus MBT may lead to a reduction in fearful attachment and improvement of affective mentalizing. Short-term combinations of evidence-based borderline treatments may enrich psychiatric inpatient care. Therefore, such approaches deserve further research. Limitations The treatment condition was therapeutically more intense than the control condition. The study lacked a follow-up assessment. The impact of comorbid conditions on treatment response was not taken into account. Adherence to the manualized approach was not measured.

Assessing Attachment Representations in Adolescents: Discriminant Validation of the Adult Attachment Projective Picture System.

The contribution of attachment to human development and clinical risk is well established for children and adults, yet there is relatively limited knowledge about attachment in adolescence due to the poor availability of construct valid measures. The Adult Attachment Projective Picture System (AAP) is a reliable and valid instrument to assess adult attachment status. This study examines for the first time the discriminant validity of the AAP in adolescents. In our sample of 79 teenagers between 15 and 18 years, 42 % were classified as secure, 34 % as insecure-dismissing, 13 % as insecure-preoccupied and 11 % as unresolved. The results demonstrated discriminant validity for using the AAP in that age group, with no associations between attachment classifications and verbal intelligence, social desirability, story length or sociodemographic variables. These results poise the AAP to be used in clinical intervention and large-scale research investigating normative and atypical developmental correlates and sequelae of attachment, including psychopathology in adolescence.

[The Munich Attachment and Effectiveness Study: Study Design and a Case Example]. / Münchner Bindungs- und Wirkungsforschungsprojekt: Studiendesign und ein Einzelfall.

OBJECTIVES: The "Munich Attachment and Effectiveness Study" is a prospective psychotherapy study examining process and outcome of psychoanalytic psychotherapies. The study design and results are exemplified in a single case. METHODS: At 6 points in time audio-taped and transcribed therapy sessions are evaluated using process instruments (e. g. Psychotherapy Process Q-Set PQS) and interviews (e. g. Operationalized Psychodynamic Diagnostics OPD, Heidelberg Structural Change Scale HSCS, Adult Attachment Interview AAI). RESULTS: In the single case, findings from the psychotherapeutic process (e. g. "therapist is empathic" according to PQS) complement the achieved changes. 5 HSCS problem foci reached level of "restructuring", on the Reflective Functioning Scale a marked change of RF took place and the attachment classification changed over time. CONCLUSIONS: The instruments employed in this study corresponded well in assessing change processes in spite of differing theoretical background.

Transference-focused psychotherapy for borderline personality disorder: change in reflective function.

Borderline personality disorder is associated with deficits in personality functioning and mentalisation. In a randomised controlled trial 104 people with borderline personality disorder received either transference-focused psychotherapy (TFP) or treatment by experienced community therapists. Among other outcome variables, mentalisation was assessed by means of the Reflective Functioning Scale (RF Scale). Findings revealed only significant improvements in reflective function in the TFP group within 1 year of treatment. The between-group effect was of medium size (d = 0.45). Improvements in reflective function were significantly correlated with improvements in personality organisation.

Tourette syndrome is associated with insecure attachment and higher aggression.

This study explored the degree to which adult patients with Tourette syndrome (TS) exhibit particular attachment styles and the possible association between the underlying attachment dimensions and forms of aggression. Fifty-three TS patients (ages 17-72 years) and 54 matched healthy controls completed the Experiences in Close Relationships-Revised Scale (ECR-R) and the Aggression Questionnaire (AQ). The data were analysed with ANOVA F-tests, t-tests, and Pearson's correlation coefficient. TS patients showed significantly higher scores in relationship anxiety ( p < 0.001) and relationship avoidance ( p = 0.001) in the ECR-R and significantly higher aggression scores in the AQ ( p < 0.001). The total AQ score correlated significantly with the ECR-R dimension anxiety ( p < 0.001). These are the first findings on TS patients' attachment styles and anger symptoms. It remains unclear whether attachment anxiety and avoidance are risk factors for TS or whether the disorder itself induces attachment disorders. Prospective studies with detailed attachment interviews would help to explore this issue.

[Attachment and psychosomatic health among Catholic pastoral professionals]. / Bindung und psychosomatische Gesundheit bei katholischen Seelsorgenden.

OBJECTIVES: The study examines attachment representations and psychosomatic symptoms of Catholic priests and other pastoral professionals in Germany. METHOD: We conducted structured biographical interviews with 83 Catholic pastoral professionals (47 priests, 36 lay pastoral workers). Attachment representations were diagnosed by use of the Adult Attachment Projective Picture System (AAP). Psychosomatic health data (Brief Symptom Inventory - BSI-18) were taken from the associated German Pastoral Ministry Study. RESULTS: In the sample, the proportion of secure attachment representations was 23%, of insecure- dismissing 39%, of insecure-preoccupied 18% and of unresolved attachment status 21%. Individuals with secure attachment representation were associated with lower values of psychosomatic stress, while individuals with insecure-dismissing and unresolved attachment status had higher values. DISCUSSION: The amount of insecure attachment representations and psychosomatic symptoms is higher than in data from the healthy samples, especially in the cohorts between 1933 and 1945. Data from biographical interviews indicate the significant role of institutional attachment to the Church, in many cases possibly compensating for dysfunctional parental relationships in personal history.